#02/2022

ISSN 2299-1247

COVID-19 SEVERITY AND MORTALITY

RATE AMONG PEOPLE IN NORTHWEST
SYRIA
DOI:10.7365/JHPOR.2022.2.5

Authors:
Kassem Ballout1
orcid.org/0000-0003-3373-2489

Nimetcan Mehmet2
orcid.org/0000-0003-3373-2489

1 - Ankara Yildirim Beyazit University-Public health institute-Health

policy and global health Department.

2 - Ankara Yildirim Beyazit University-Faculty of medicine – Public

health department.

Keywords:
COVID-19, coronavirus, non-communicable diseases, vaccination,
Northwest Syria

Copyright: © 2022 PRO MEDICINA Foundation, 43 Published by PRO MEDICINA Foundation

User License: The journal provides published content under the terms of the Creative Commons 4.0 Attribution-International Non-Commercial Use (CC BY-NC 4.0) license.
 COVID19- SEVERITY AND MORTALITY RATE AMONG PEOPLE IN NORTHWEST SYRIA
How to cite this article?
Ballout K., Mehmet N., COVID-19 SEVERITY AND MORTALITY
RATE AMONG PEOPLE IN NORTHWEST SYRIA, J Health Policy
Outcomes Res [Internet]. 2022[cited YYYY Mon DD];. Available from:
http://jhpor.com/article/2301-covid-19-severity-and-mortali-
ty-rate-among-people-in-northwest-syria
contributed: 2022-12-05
final review: 2022-12-30
published: 2022-12-30
Corresponding author:
Kassem Ballout kassemballout1984@gmail.com
ABSTRACT
Background: The first COVID-19 case in Northwest
Syria (NWS) was detected by July 2020. The data were
presented in the Early Warning and Alert Response Net-
work (EWARN) regular reports and updates about the
COVID-19 outbreak developments.
Methods: This research is a retrospective cross-sectional
study of the COVID-19 reported cases in NWS, which is
aimed to determine the impact of age, non – communi-
cable diseases (NCDs), and vaccination status on the case
severity and mortality rate among COVID-19 patients.
Results: By Oct 2021, there were 88,421 COVID-19 posi-
tive cases, 1,362 (1.54%) deaths were reported and 66,006
(74.65%) recovered. The severity of the clinical status of
the COVID-19 cases increased with age going up, 58% out
of the severe cases were for people 60+ years old, 7.7% of
the server cases had at least one NCD, while it was less
among people who got at least one dose of COVID-19
vaccines, only 0.8% of the cases had severe symptoms.
70% of the deaths were from the age group of people who
were 60+ years old. The COVID-19 mortality rate among
patients with NCD demonstrated that death was 5 times
more among people with at least one NCD 7.1% compared
to people without NCD 1.4%, and 99% of the cases didn’t
get vaccinated.
Conclusion: The severity of the disease increased with
age, in the presence of any NCD. The study findings add-
ed more evidence that by increasing the vaccination cov-
erage, more fatalities can be avoided, particularly among
the elderly and those with NCDs.
44
Background:
COVID-19 is a disease caused by a virus named Severe
Acute Respiratory Syndrome Coronavirus 2 (SARS-
CoV-2) and was discovered in December 2019 in Wuhan,
China.[1] After a few months, it was spread throughout
most countries of the world and considered pandemic by
WHO in March 2020. COVID-19 is characterized clini-
cally by respiratory symptoms ranging from a mild respi-
ratory infection (including fever, cough, and fatigue) to
pneumonia, acute respiratory distress syndrome (ARDS),
shock, and death. Although the lungs are the most affected
parts of the patient’s body, other parts may also be affected
by the inflammatory and immunological processes.
It is a very contagious disease and like other respiratory
viruses, coronaviruses spread quickly through droplets
that the patients generate when they sneeze, cough, speak,
or even breath.[2] People of any age might get infected
by SARS-CoV-2. Most people with COVID-19 have mild
symptoms or sometimes no symptoms, but some people
become severely ill.[2] Older people (more than 65), and
people with pre-existing conditions (such as heart diseas-
es, hypertension, diabetes, and respiratory conditions)
appear to be more susceptible to becoming severely ill
with the virus and suffer worse consequences.[3] The se-
vere disease means that the person with COVID-19 may
be hospitalized, need intensive care, require a ventilator
to help them breathe, or die.[4] This is due to people living
with NCDs being at increased risk of becoming severe-
ly ill with the virus as well as the disruption of health
services is particularly problematic for those living with
NCDs who need regular care.
In addition to symptomatic management, several thera-
peutic options are now available for the treatment of in-
dividuals with COVID-19, [5] and numerous randomized
controlled trials (RCTs) are underway. However, uncer-
tainties remain about the efficacy of existing treatments
for COVID-19 – against emerging SARS-CoV-2 variants.
Since treatment is not available in most countries, es-
pecially the low-income ones, all the developed and ap-
proved vaccines are highly effective at preventing severe
diseases, hospitalizations, and deaths, [6] however, cases
of infection are expected among fully vaccinated people,
but limitations in global access to vaccines mean that
many populations remain vulnerable. Even in vaccinat-
ed individuals, uncertainties remain about the duration
of protection and efficacy of current vaccines, [7] the pre-
ventive measures are still valid and important to protect
yourself and slow the spread of SARS-CoV-2; 1) keep the
social distance at least 1 meter away from others, even if
they don’t have symptoms because they might be asymp-
tomatic infected, 2) wear a mask especially when social
 COVID19- SEVERITY AND MORTALITY RATE AMONG PEOPLE IN NORTHWEST SYRIA
distancing is not achievable, 3) avoid crowded or poorly
ventilated places, 4) clean surfaces regularly and avoid
touching surfaces in public settings, 5) frequently clean
your hands with soap and water, or an alcohol-based
hand rub, 6) apply respiratory etiquette and cover your
coughs and sneezes with a bent elbow or tissue, throwing
used tissues into a closed bin right away. Then wash your
hands or use an alcohol-based hand rub.
By March 4. 2022 there have been 440,807,756 confirmed
cases of COVID-19, including 5,978,096 deaths, reported to
WHO. As of 26 February 2022, a total of 10,585,766,316 vac-
cine doses have been administered.[8]
In Syria where the conflict during the last eleven years
has created one of the most severe and complicated hu-
manitarian crises in the world today by ongoing hostili-
ties which have killed hundreds of thousands of people,
triggered one of the worst displacement crises of our
time, and led to the multisectoral collapse. Millions have
left their homes and become internally displaced peo-
ple inside Syria or refugees outside Syria. In Northwest
Syria which is under the opposition groups’ control and
depends on crossing border modality from Turkey to get
humanitarian assistance including health, there are about
4.4 million living there and almost 3.5 million are people
in need.[9] The first case of COVID-19 in Northwest Syria
was detected on July 9. 2020.[10] Northwest Syria has wit-
nessed three waves of COVID-19 from Jul 2020 to Dec
2021. The third wave started in Aug 2021 and was the
most severe wave of COVID-19 that hit Syria. In north-
west Syria, the number of confirmed cases of COVID-19
almost doubled in Oct 2021, [11] reaching nearly 83,000
compared to about 41,000 cases recorded by the end of
August 2021. The positivity rate of the tests reached 61%
in Oct 2021. Worth mentioning that the vaccination ac-
tivities against SARS-CoV-2 started in May 2021, when
the first vaccination campaign was kicked off in North-
west Syria.[12] The target was vaccinating the health care
workers who are on the front line dealing with suspect-
ed or confirmed COVID-19 cases in the health settings
in addition to the high-risk population groups who were
associated with chronic morbidities then extended to all
individuals above 18 years old. By March 2. 2022, 98,213
confirmed cases of COVID-19 including 2,395 deaths.
A total of 527,843 vaccine doses were administered with
about 15.96% of the targeted population (more than 18
years old) being vaccinated.[13]
The study aimed to determine the impact of age, non –
communicable diseases as co-morbidities, and vaccina-
tion status on the severity of the clinical situation and
mortality rate of COVID-19 patients.
Materials and Methods:
45
Methods:
This is a cross-sectional study that was done retrospec-
tively for people in NWS who were exposed to the SARS-
CoV-2 virus and the study observed and analyzed the dif-
ference in the outcome.
Knowing that during the COVID-19 waves, the level of
transmission reached level 4 of community transmission
which means that anyone was exposed to get infected
wherever you were living in NWS.
Data collection:
According to the health cluster preparedness plan, health
settings in NWS were applying triage protocols at the
entrance of the health settings as part of the Infection
Prevention and Control (IPC) pillar - whether triage
was applied in a dedicated space in the health setting or
not. Well-equipped health workers were screening peo-
ple who were seeking health care to identify if they had
any symptoms, or signs of COVID-19 to be sent to the
general practitioner in the same health setting for further
assessment. Then if the case was a probable or a suspect-
ed case of COVID-19, EWARN focal points in the field
would be contacted to arrange sampling whether in the
health facility itself or the COVID-19 Community Treat-
ment Centers CCTCs or the isolation COVID-19 center
according to the case condition. The samples then were
sent to the respected EWARN Polymerase chain reaction
(PCR) lab in Idleb or Afrin regions to be tested. Accord-
ing to the results, EWARN teams and focal points were
conducting contact tracing – if the results came positive-
to collect samples from close contacts.
Moreover, to enhance the surveillance measures, EWARN
teams were collecting random samples – from symp-
tomatic and asymptomatic cases - as screening from the
high-risk transmission areas, camps, and health settings.
All the names were anonymous and unique patients’
codes were used instead. All cases since the first detect-
ed case in NWS till the end of Oct 2021 were reported
in the EWARN regular reports and updates about the
COVID-19 development in NWS. In the group of study,
all tested positive for COVID-19. The data collected were
segregated by age, gender, place of living, vaccination sta-
tus, if they had co-morbidities, especially non-communi-
cable diseases or not, clinical status once diagnosed, and
the outcome.
Results:
The study group consisted of a total of 88,421 positive
COVID-19 cases in Northwest Syria. The samples were
collected from the patients who met the definition of
COVID-19 suspected case according to WHO definition.[14]
 COVID19- SEVERITY AND MORTALITY RATE AMONG PEOPLE IN NORTHWEST SYRIA
The samples were tested in 6 labs in NWS: 2 labs in Alep-
po governorate and 4 labs in Idleb governorate.
Here in the discussion of the results, we will present the
impact of the independent variables; age, non-communi-
cable diseases as co-morbidities, and vaccination status
on the severity and outcome of the COVID-19 infection
taking into consideration the severity levels according
to WHO that the person with COVID-19 may be hospi-
talized, need intensive care, require a ventilator to help
them breathe, or die, [4] and the definition of death due to
COVID-19 which is defined for surveillance purposes as
a death resulting from a clinically compatible illness in
a probable or confirmed COVID-19 case unless there is
a clear alternative cause of death that cannot be related
to COVID-19 disease (e.g., trauma). There should be no
period of complete recovery between illness and death.[15]
Knowing that according to WHO 80% of COVID-19 cases
have mild or moderate clinical status while only 15% de-
velop severe disease and need oxygen and 5% have critical
disease.[2]
As shown in table 1, the majority 74,469 (84.22%) were
in the 19 – 65 age group. Out of the study group, 50,095
(56.66%) were males. Northwest Syria had witnessed three
waves of COVID-19 from Jul 2020 to Dec 2021. The third
wave started in Aug 2021 and was the most severe wave
of COVID-19 that hit Syria with about 62,437 confirmed
COVID-19 cases which were 70.61% of the study group.
Regarding the COVID-19 associated deaths as demon-
strated in table 2, there were 1,362 deaths as an accumu-
lative number during the last three waves in NWS. The
multitude of deaths was from the age group of people who
were 60 and above years old with almost 70% of all deaths.
Furthermore, including all reported cases in NWS by Oct
2021 and considering the age group 18 to 29 years old as
a reference group – since it has accounted for the largest
cumulative number of COVID-19 cases compared to oth-
er age groups, the mortality rate was 6.3 times higher in
50- to 59-year-olds, and 17.2 times higher in those who are
70 years and older. On top of that, the prevalence of severe
clinical status increased as well as the age was going up. It
was 3 times and 5.6 times in the age groups of 50-59 and
70+ respectively compared with the reference group 18- to
29-year-old.
For the non-communicable (NCD) cases in the study
group, there were 1,698 (2%) patients who have at least one
NCD. Most of them, 950 (41%) have hypertension, and 826
(35%) have diabetes while heart disease and chronic respi-
ratory diseases were 11% and 9% respectively.
Patients with at least one NCD were shown with increas-
ing severity of the COVID-19 infection and deteriorating
clinical status of the patient. Only 0.2% of the asymptom-
atic patients had at least one of the NCDs, while the per-
46
centage increased to reach 7.7% of the server cases had at
least one NCD. This means in other words that once they
got infected by the virus, patients with chronic diseases
had a much higher likelihood of having worse clinical out-
comes than an average patient.
Furthermore, 9% of all deaths were for people who had
at least one NCD. Calculating the COVID-19 mortali-
ty rate among patients with NCD (table 3) demonstrat-
ed that death was 5 times more among people with at
least one NCD (7.1%) compared to people without NCD
(1.4%) which indicates that those who have at least one
NCD were more likely to die due to COVID-19.
The majority of deaths were among people with renal dis-
eases, seizures, obesity, and cancer cases. The COVID-19
mortality rate among patients with Chronic Respiratory
Disease was relatively low in comparison to other NCDs
and it might be due to the misdiagnosing of the cases as
asthma or COPD without matching the international cri-
teria which lead to overestimating the total number of
cases.
While for the vaccination impact, the prevalence of
COVID-19 among vaccinated people (who got at least
one dose) was significantly lower than those among un-
vaccinated ones, they were 2,625 (2.97%) and 85,796
(97.03%) respectively. Similar trends were noted for dif-
ferences in the severity of the clinical status among these
groups. 3.3% of the vaccinated people had mild symptoms
while the percentage dropped to 0.8% in the severe symp-
toms group.
In the study group, the COVID-19 associated deaths
were 1,351 (99%) and 11 (1%) deaths among unvaccinated
and vaccinated persons, respectively. As shown in table 4,
calculating the mortality rate among the vaccinated
group indicates that those who took at least one dose of
COVID-19 vaccines were three times less likely to die due
to COVID-19 (0.4%) compared to those who didn’t take
vaccines (1.6%).
Taking into consideration age and existence of at least
one NCD among the vaccinated people indicated that
the COVID-19 mortality rate among infected people who
were 60+ years old and got vaccines was (1%) compared
to those who didn’t get the vaccine (4.2%). Similarly, the
mortality rate among infected people who had at least one
NCD and got vaccines was (4.7%) compared to those who
didn’t get the vaccine (7.1%), as demonstrated in table 5.
 COVID19- SEVERITY AND MORTALITY RATE AMONG PEOPLE IN NORTHWEST SYRIA

Discussion:
During the last three waves of COVID-19 in Northwest
Syria, there were 88,421 COVID-19 positive cases by end
of Oct 2021 and 1,362 deaths. The severity of the clinical
status of the COVID-19 cases was increased by 1) age go-
ing up, 295 (58%) out of 508 severe cases were for people
60+ years old, and 2) if the patients had at least one NCD
39 (7.7%). While it was less among people who got at least
one dose of COVID-19 vaccines, only 4 (0.8%) cases had
severe symptoms.

The majority of the deaths 951 (70%) were from the

age group of people who were 60+ years old. Out of the
deaths, there were 120 (9%) cases had at least one NCD.
The COVID-19 mortality rate among patients with NCD
demonstrated that death was 5 times more among people
with at least one NCD (7.1%) compared to people without
NCD (1.4%). And 1,351 (99%) cases didn’t get vaccinated.
All cases included in the EWARN report were for pa-
tients with positive results of SARS-CoV-2 only, which
means in other words that the report doesn’t include all
the classified COVID-19 death cases (16), according to the
WHO definition of the COVID-19 death case. Moreover,
in the last wave of COVID-19 which reached the peak in
mid of Sep 2021 with nearly 1500 daily cases, the occu-
pancy rate of the COVID-19 dedicated hospitals reached
100% and exceeded 90% in the COVID-19 Community
Treatment Centers CCTCs, [17] in addition to the severe
shortages in the oxygen in the NGO supported health
settings (18), which overwhelmed the capacity of the al-
ready-stretched health settings, [19] and obliged people to
seek medical care in the privet sector which is already not
well equipped due to the conflict challenges. In addition
to a lack of well-qualified health staff due to the crisis who
might already be negatively affected by the COVID-19
pandemic.[20,21] This means that not all COVID-19 cases
or deaths were registered or even followed by the EWARN
teams on the ground and the situation might be worse
than reported. As per the above discussion, we can con-
clude that the severity of the disease increased with age,
in the presence of a non – communicable disease, and if
the patient was not vaccinated. The study findings added
more evidence that by increasing vaccination coverage,
more fatalities can be avoided, particularly among the el-
derly and those with non-communicable disorders.

The authors declare no conflict of interest.

Funding: none

47
 COVID19- SEVERITY AND MORTALITY RATE AMONG PEOPLE IN NORTHWEST SYRIA

Tables:
Table 1: Sociodemographic factors of the patients
Characteristics N %
Age group
0 – 18 years 9,381 10.61%
19 – 59 years 70,038 79.21%
60 + years 9,002 10.18%
Gender
Male 50,095 56.66%
Female 38,326 43.34%
Governorate
Aleppo 35,283 39.90%
Idleb 53,138 60.10%
Live in a camp
Yes 10,930 12.36%
No 77,491 87.64%
Clinical Status at the time of diagnosis
Asymptomatic 9,414 10.65%
Mild 75,161 85.00%
Moderate 3,338 3.78%
Sever 508 0.57%
Vaccination Status
Yes (at least one dose) 2,625 2.97%
No 85,796 97.03%
With at least one NCD
Yes 1,698 1.92%
No 86,723 98.08%
Outcome
Alive 21,053 23.81%
Deceased 1,362 1.54%
Recovered 66,006 74.65%

Table 2: The prevalence of severe clinical status and mortality rate among COVID-19 cases by age group:
40-49 years 60-69 years
0-5 years old 6-18 years old 19-29 years old 30-39 years old 50-59 years old 70+ years old
old old
Reference
Cases 846 8,535 23,444 12,506 8,277 5,262 3,740
group (25,811)
Clinical Status Reference
7 8 1.4x (44) 1x (33) 3x (90) 3.9x (120) 5.6x (175)
- Sever group (31)
Reference
Death <1x (3) <1x (18) 1.9x (62) 2.6x (87) 6.3x (208) 11.6x (382) 17.2x (569)
group (33)

Table 3: The COVID-19 mortality rate per NCD

The outcome of COVID-19 infection
Total COVID-19 mortality rate
Total Deaths Recovery and Alive
Without NCD 86,723 1,242 85,481 1.4%
With at least one NCD 1,698 120 1,578 7.1%
1. Cancer 11 2 9 18.2%
2. Heart Diseases 269 36 233 13.4%
3. Hypertension 950 70 880 7.4%
4. Diabetes 826 72 754 8.7%
5. Chronic Respiratory
199 6 193 3.0%
Disease
6. Obesity 9 3 6 33.3%
7. Seizures 4 1 3 25.0%
8. Renal Diseases 62 13 49 21.0%

48
 COVID19- SEVERITY AND MORTALITY RATE AMONG PEOPLE IN NORTHWEST SYRIA

Table 4: Mortality rate among vaccinated (at least one dose) and not vaccinated patients of COVID-19

The outcome of COVID-19 infection

Total COVID-19 mortality rate
Total Death Recovery and Alive

Vaccinated (at least one dose) 2,625 11 2,614 0.4%

Not vaccinated 85,796 1,351 84,445 1.6%

Table 5: Mortality rate of the COVID-19 patients who were 60+ years old and those who have at least one NCD regarding the vaccination status.

The outcome of COVID-19 infection

Total COVID-19 mortality rate
Total Deaths Recovery and Alive

60+ years old patients (Total: 9002 patients)

COVID-19 cases for 60+ years old and got at
142 6 136 4.2%
least one dose of vaccines
COVID-19 cases for 60+ years old and didn’t get
8,860 945 7,915 1%
vaccinated
NCD patients (Total: 1698 patients)
COVID-19 cases with NCD and got at least one
43 2 41 4.7%
dose of vaccines
COVID-19 cases with NCD and didn’t get
1,655 118 1,537 7.1%
vaccinated

49
 COVID19- SEVERITY AND MORTALITY RATE AMONG PEOPLE IN NORTHWEST SYRIA

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